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NEWPORT INTERNATIONAL JOURNAL OF RESEARCH

IN MEDICAL SCIENCES (NIJRMS)
Volume 3 Issue 3 2023
Page | 91

Assessment of risk factors for severe acute

malnutrition in children below the age of five
admitted in malnutrition unit at Mubende regional
referral hospital, Uganda

Mugyema David

Department of Medicine and Surgery, Kampala International

University, Uganda
ABSTRACT
The study assessed the risk factors for severe acute malnutrition in children below the age of 5 admitted in
Malnutrition Unit at Mubende Regional Referral Hospital. The specific objectives of the study were; to assess the
parental risk factors for severe acute malnutrition in children below the age of 5 admitted in Malnutrition Unit at
Mubende Regional Referral Hospital and to assess the child risk factors for severe acute malnutrition in children
below the age of 5 admitted in Malnutrition Unit at Mubende Regional Referral Hospital. A descriptive facility-
based cross- sectional study design was used which was applied to both qualitative and quantitative approaches.The
study population was all patients with severe acute malnutrition below the age of 5 admitted in Malnutrition Unit
at Mubende Regional Referral Hospital. 261 respondents were a representative sample to take part in this study.
Data was collected chiefly through a researcher- administered questionnaire specifically tailored to meet the
objectives of the study and supportedby anthropometric measurements and clinical evaluation and diagnoses. Data
analysis was done as per objective; descriptive statistics in form of percentages, charts, tables or graphs with
univariate, bivariate or multivariate analytical method. According to the findings, household was factors for severe
acute malnutrition in children below the age of 5 admitted in Malnutrition Unit at Mubende Regional Referral
Hospital. Majority of respondents lived in semi-permanent house constituting (49.8%), 19.2% lived in temporary
house, while 31.0% was within permanent house.The findings implied that majority of respondents were considered
in the middle income as they lived in a semi-permanent house. The study concluded that illiteracy and poverty were
the major factors contributing to malnutrition in children while recurrent diarrhea and nonexclusive breast feeding
were directly responsible for it. The study recommended that Health workers should do village outreaches to
sensitize parents on prevention of malnutrition and advocate for early seeking of health services in case. The
government should provide income generating activities for those in the informal sector, so that they can make extra
income to feed their children and prevent malnutrition.
Keywords: Assessment, risk factors, acute malnutrition and children

INTRODUCTION
Malnutrition is the condition where by an individual can have over nutrition (excess nutrients) or under nutrition
(nutrient deficiency). Under nutrition is categorized as: acute (recent) or chronic (long-term). It is caused by
inadequate intake or poor absorption of nutrients in body. Under nutrition has four (4) forms; acute malnutrition,
Stunting, underweight and micronutrient deficiencies. The 4 forms can be categorized moderate or severe [1].This
research will focus on severe acute malnutrition (SAM) and SAM is characterized by bilateralpitting edema or severe
wasting. Several indicators can be used to measure acute malnutrition [2]. These include: height for age, weight for
height, weight for age, mid upper arm circumference, body mass index and Z scores.
Height for Age: This is a measure of linear growth, and deficit represents the cumulative impactof adverse events,
that ultimately results in stunting or chronic malnutrition.
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Height /Age: (Height of child / Height of normal child of same age) ×100.
Weight for Height: Low weight for height indicates Acute Malnutrition.
Weight / Height: (Weight of child / Weight of normal child of same height) × 100
Weight for Age: Weight / Age: (Weight of child / Weight of normal child of same age) ×100
Mid Upper Arm Circumference (MUAC): Used for screening wasted children.
Body mass Index (BMI): It is a screening tool for thinness, overweight and obesity.
BMI = Weight in Kg/square of height in meters.
Z score: It is the child’s height minus the median height for the age and sex of the child divided by relevant standard
Page | 92
deviation. Development of SAM is associated with several factors. Among these are: Socio-economic status,biological
factors, environmental factors, role of free radicals, age of the host etc. Some of the socio-economic, biological and
environmental factors are: lack of breast feeding and giving diluted formula, improper complementary feeding,
overcrowding and poor child-spacing in family,ignorance, illiteracy, lack of health education (awareness), poverty,
concomitant infections,familial disharmony among others [3]. Two new theories associated with SAM (specifically
in the pathogenesis of Kwashiorkor) have emerged lately vis the role of free radicals and the age of the host [4].
The free radical theory postulates that free radical damage to hepatocytes give rise to Kwashiorkor whereas the age
of thehost theory applies frequently in infants and young children whose rapid growth increases their nutritional
requirements hence predisposing to Kwashiorkor [4].
Malnutrition is a special public health problem, especially in developing countries. About 95% ofall malnourished
people live in the subtropics and tropics of Africa and Asia. More than 70% of children with SAM live in Asia and
26% in Africa, and 4% in Latin America and the Caribbean [5]. Malnutrition is by far the biggest contributor to
child mortality: 49% of the 10.4 million deaths occurring in the under-fives in developing countries are associated
with SAM. 6 million children die of hunger every year [1, 5]. When the nutritional status of a child deteriorates in a
relatively short period of time, the child can be said to have acute malnutrition. If a child’s weight for height
measurement is less than 70% ofthe normal range for his age (weight for height Z score <-3SD), then the child would
be diagnosedas having severe acute malnutrition. Another criterion is when the child’s MUAC is less than 11 cm
[6]. Acute malnutrition is a devastating public health problem of epidemic proportions. Worldwide, about 55 million
under five children suffer from acute malnutrition and an estimated 26 million of them had severely acute
malnourished, most of who live in sub-Saharan Africa and South Asia. Every year, 3.5 million children die of
malnutrition related causes. Among this, severe acute malnutrition contributes to 1 million deaths of children
annually [7]. SAM is a deadly condition. It kills children by increasing the case fatality of common childhood
infections, and therefore it is an immediate or direct cause of child death. Malnourished children, who are ill, die
because they are malnourished. Mortality rates in SAM children are 9 times higher than those in well-nourished
children. According to the Maternal and Child Under nutrition Study Group, 3.5 million child deaths, 35% of the
disease burden in childrenyounger than 5 years, and 11% of total global disability-adjusted life-years (DALY) are
attributable to maternal and child under nutrition [8]. It was estimated by the samegroup that stunting, severe
wasting, and intrauterine growth restriction together were responsible for 2.2 million deaths and 21% of DALYs
for children below five years of age [7].
Karamoja sub-region which is a semi-arid area of northern Uganda that borders Kenya and SouthSudan has the
highest burden of malnutrition compared with the rest of the country (Uganda Bureau of Statistics [9]. About 3.8%
(95% CI; 3.2- 4.5) of the children younger than five years are severely wasted in Karamoja Region. Stunting
and underweight rates amongst children under 5 years stand at 39.5% and 31% respectively [10]. Majority (80%) of
Karamojong live below the poverty line [11]. andnearly half of all households (46%) in Karamoja are said to be food
insecure [10]. About 79% of the poor households are less likely to have at least two meals a day than those living
above the poverty line [12]. Less than half of Karamoja’s children receive a minimum frequency of meals for their
age [10]. Only 3% of children are fedadequately in terms of diet diversity and meal frequency recommended by WHO
[10].The SAM children are more vulnerable to infections because of the effect of SAM on their body metabolism
and require high quality of care to catch up with growth and development [13]. A discussion with UNICEF revealed
that cases of children exiting the treatment program after being successfully cured and discharged reappear for re-
admission after relapsing to SAM [14]. The Ugandan Government rolled out Integrated Management of Acute
Malnutrition(IMAM) Guidelines for treating children with SAM to facilitate integration of treatment of SAM in
the existing health system [15]. Over 103 SAM treatment centres have been established in Karamoja Region. It is
reported that 10,000- 11,500 SAM cases are treated annually in the Karamoja Region [16]. It has also been reported
that only half of SAM children (49.7%) receive treatment in the Karamoja Region [16]. Globally, approximately 52
million (8%) children under the age of five years in 2011 were wastedand more than 70% were from Sub-Saharan
Africa and Asia [18]. In Uganda, the national prevalence of acute malnutrition (wasting) among children 6-59
months of age is 4% and it is 10% for West Nile sub- region [19-23]. In South Sudan where most of the refugees in
Uganda originate from, there is critical food shortage and famine is looming with prevalence of acute malnutrition
in some areas estimated at 26.1% [24-29]. Despite the overall improvement in lowering of chronic malnutrition over
the past five years, the proportion of children who are wastedhas remained almost unchanged (6% in 2006 to 5% in
2011) in Uganda, there are significant disparities in malnutrition between the regions of the country [30-31].
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Because of this reason this study sought to assess the risk factors for severe acute malnutrition in children below
the age of 5 admitted in Malnutrition Unit at Mubende Regional Referral Hospital. Specific objectives is to assess
the parental risk factors for severe acute malnutrition in children below the age of 5admitted in Malnutrition Unit
at Mubende Regional Referral Hospital, and also to assess the child risk factors for severe acute malnutrition in
children below the age of 5admitted in Malnutrition Unit at Mubende Regional Referral Hospital.
METHODOLOGY
STUDY DESIGN
A descriptive facility-based cross-sectional study design was used which was applied to both qualitative and Page | 93
quantitative approaches.
STUDY AREA
The study was conducted at Mubende Regional Referral Hospital.
STUDY POPULATION
The study population was all patients with severe acute malnutrition below the age of 5 admitted in Malnutrition
Unit at Mubende Regional Referral Hospital
INCLUSION CRITERIA
All patients with severe acute malnutrition below the age of 5 admitted in Malnutrition Unit at Mubende Regional
Referral Hospital within the time scope of the study and whose caretakers consented were included in the study.
EXCLUSION CRITERIA
All patients without severe acute malnutrition below the age of 5 admitted in Malnutrition Unit atMubende Regional
Referral Hospital, patients with severe acute malnutrition above the age of 5 admitted in Malnutrition Unit at
Mubende Regional Referral Hospital and those whose caretakersrefuse to offer consent was excluded.
SAMPLE SIZE DETERMINATION
Sample size was calculated using [21].
formula,
𝑍2𝑃𝑄
N=
𝐷2
Where N is the desired sample size
Z is the standard normal deviation taken as 1.96 at a confidence interval of 95%.P is the
prevalence = 21.7% (Buena, 2005, Mulago hospital Kampala).
D is the degree of accuracy= 0.05.
Q= (1-P) which is the population without the desired characteristics = (1-0.497) =0.783
1.962×0.217×0.783
N= =261.09
0.05

Therefore 261 respondents were a representative sample to take part in this study.

SAMPLING PROCEDURES

Simple random sampling technique was used whereby study subjects were recruited as they comeand meet the
inclusion criteria.

DATA COLLECTION METHODS AND MANAGEMENT

Data was collected chiefly through a researcher-administered questionnaire specifically tailored tomeet the objectives
of the study and supported by anthropometric measurements and clinical evaluation and diagnoses. Data collected
was tallied, tabulated and charted in away that reflectedthe study objectives.
DATA ANALYSIS

Data was entered into Microsoft excel 2010 professional spreadsheets and analyzed using SPSS version 17.0. Data
analysis was done as per objective; descriptive statistics in form of percentages, charts, tables or graphs with
univariate, bivariate or multivariate analytical method.
QUALITY CONTROL

A minimum of 20 questionnaires that were not in part of the study were pretested for accuracy andability to meet the
set objectives. Corrections will be done where necessary.
ETHICAL CONSIDERATIONS
Clearance was obtained from Kampala International University-Western Campus faculty of clinical medicine &
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dentistry through IREC and an introductory letter which was presented to the administration of MRRH. The
researcher affirmed the use of the information obtained for researchpurposes only and it was not to reveal to any
unauthorized parties.
LIMITATIONS / DE-LIMITATIONS OF THE STUDY
Language barrier can be the outstanding barrier to this research as the researcher cannot speak thelanguage of the
research participants, and the interpreter may not be able to translate the exact words of the participant to the
researcher. Also the questionnaires were designed in English whichmay be hard for some research participants that
cannot speak English to respond correctly. Page | 94
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RESULTS
The study was ‘To assess the risk factors for severe acute malnutrition in children belowthe age of 5 admitted in
Malnutrition Unit at Mubende Regional Referral Hospital”. It was a crosssectional study that saw 261 participants
recruited. Results were then analyzed using statistical methods and presented in form of tables and pie charts.
Response Rates
A total of 261 questionnaires were given to all patients with severe acute malnutrition below the age of 5 admitted
in Malnutrition Unit at Mubende Regional Referral Hospital all 261 questionnaires were fully returned complete.
Socio-demographics of the respondents Page | 95
Table 1: Socio-demographics of the respondents

AGE FREQUENCY PERCENTAGE

15-25 60 22.9%
26-35 100 38.3%
36-45 81 30.1%
46 and above 20 7.6%
Total 261 100
Marital status
Single 61 23.4%
Married 200 76.6%
Total 261 100
RELIGION
Christian 160 61.3%
Muslim 60 22.9%
Other Religion 41 15.7%
Total 261 100
LEVEL OF EDUCATION
Primary 100 38.3%
Secondary 148 56.7
College 10 13.9
Others 3 1.1
Total 261 100

Most of the participants were between the age of 26-35 (38.3%) followed by those of 36-45 (30.1%), 46 and above
(7.6%). Most of the participants were married (76.6%) while (23.4%) were single
Most of the respondents were of the Christian denomination (61.3%) followed Muslims with 22.9% unlike 15.7%
were other religions. The findings indicated that majority of respondents whoinvolved in the study were Christians.
For the case of education level, most of the respondents were secondary holders (56.7%), 38.3 hadprimary level, 13.9%
had attained college level unlike (1.1%) had other qualifications.
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Socio-economic factors
Table 2. Socio-economic factors

Socio- economic factors Frequency Percentage

House hold
Temporally house 50 19.2
Semi-permanent 130 49.8 Page | 96
Permanent house 81 31.0
Total 261 100
Occupation
House wife 115 44
Farmer 91 34.9
Business 30 11.5
Civil servant 15 5.7
Others 10 3.8
Total 261 100
Money earned per month
Below 100,000 UgX 88 33.8
100,000 – 500,000 UgX 120 45.9
Above 500,000 Ugx 53 20.3
Total 261 100
Number of times food bought
in a week?
Once 60 22.9%
Twice 100 38.3%
Thrice 81 30.1%
Daily 20 7.6%
TOTAL 261 100
Amount of money spent on
food in a month?
Below 50,000 UgX 88 33.8
50,000 – 100,000 UgX 120 45.9
Above 100,000 UgX 53 20.3
Ownership of the following
Radio 169 64.8
Bicycle 22 8.4
T.V set 60 23
Motorbike 10 3.8
TOTAL 261 100
Type of the roof for the
main house
grass thatched 60 22.9%
Tins 100 38.3%
Iron sheets 81 30.1%
Tiles 20 7.6%
261 100

According to the findings, household was factors for severe acute malnutrition in children below the age of 5
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admitted in Malnutrition Unit at Mubende Regional Referral Hospital. Majority of respondents lived in semi-
permanent house constituting (49.8%), 19.2% lived in temporary house,while 31.0% was within permanent house.
The findings implied that majority of respondents wereconsidered in the middle income as they lived in a semi-
permanent house.
On occupation, majority of respondents were housewives constituting 44%, 34.9% were farmers, 21.4% were
housewives, 11.5% were business holders, 5.7% were civil servants unlike 3.8% werenone of the above mentioned
occupations. On the money earned per month, 33.85 earned below 100,000 UgX, 45.9% earned 100,000 – 500,000
UgX while 20.3% earned above 100,000 UgX. The findings implied that respondents hadsome money to cater for Page | 97
their children though could not be enough for. Also respondents were asked the number of times food bought in a
week, it is revealed that the food is bought once in a week (22.9%), (38.3%) bought twice in a week, (30.1%) bought
thrice in a week unlike 7.6% revealed that the food is bought daily in a week. The findings showed that few of
respondents buy foods regularly in a week. Thus their children could not get enough food as concerned. Respondents
were also asked whether they own the following; majority 64.8% of respondents hadradios, 8.4% had bi-cycle, 23%
had TV set, while 3.8% had motorbike. Respondents were also asked the type of the roof for the main house. This
was intended to know the status of the respondents as they lived. 22.9% lived in grass thatched house, 38.3% had
tins, and 30.1% had iron sheets while 7.6% had their house tiled. Majority of respondents lived in the middle income
status as they live in iron sheet houses. Respondents were also asked about birth maturity. From the study findings
majority of children 65% were delivered by preterm birth while 35% were delivered by term birth. The findings
showed that majority of respondents produced children before their maturity thus they are easily affected by
malnutrition.

35%

65%

Term birth Preterm birth

Figure 1: Children birth maturity

Majority 48% of children had normal weight, 13% had extremely low birth weight, 22% had low birth weight while
17% had very low birth weight
Respondents were also asked about birth order the results were summarized in the figure below
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Sales

13%
48% 17%
Page | 98
22%

ELBW VLBW LBW Normal

Figure 2: children’s birth order

On the information about breast feed and feeding patterns, respondents were asked whether they breastfeed their
children for six months. The results are summarized below in the table
Table 3: response on breast feeding and feeding patterns

Do you breastfeed your children for six Frequency Percentage

months
YES 100 38.3
NO 161 61.7
TOTAL 261 100

Majority 61.7% of respondents do not breast their children for six months while 38.3% breastfedtheir children for
six months. The findings implied that children were likely to have malnutritionsince they are not breastfed properly.

Table 4 Child breastfeeding and feeding habits

Number of times the child isbreastfed

1-2 times 115 44

3-4 times 91 34.9
5-6 times 30 11.5
7-8 times 15 5.7
8 and above times 10 3.8
Total 261 100
If stopped breastfeeding
before 24months, what werethe reasons

Mother became pregnant 80 30.3

Mother became sick 100 35.7

Child refused 81 31

Total 261 100

Has this child been introducedto other foods
other than
breast milk
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YES 188 72.1
NO 73 27.9
Total 261 100

Also on children’s breastfeeding, mothers were asked the number of times the child is breastfed, majority of 44% of
mothers revealed that a child is breastfed 1-2 times daily while the least 3.8%showed that the child is breastfed 8
and above times. The findings implied that mothers fear to breastfeed their more times daily because they don’t Page | 99
want their breasts to lose. This was commonly found on mothers who were between 18- 35 years.
Mothers who stopped breastfeeding their children before 24 months were asked the reason and majority 35.7%
revealed that most of mothers became sick unlike few of 30.3% mothers showedthat mothers were pregnant.
Further findings also showed that 72.1% of mothers have introduced their children to other foodsother than milk
unlike few of 28.9% did not introduce their children to other foods. From the study findings, those who revealed
that their children were introduced to other foodsother than breast milk. The results were summarized below;
Table 5: Introducing the child to other foods
N=188

Why did you decide to introduce these Frequency Percentage

foods?

Advised at the clinic 68 36.2

Child was old enough 110 58.5

I felt that breast milk was no longer adequate 10 5.3

TOTAL

Which food did you first introduce to the

child?

Cow milk 120 63.9

Porridge (millet) 11 5.8
Meat 36 19.1
Eggs 21 11.2
Total 188

According to the table above, those who introduced their children to other foods the reason wasthat they got
advice from the medical officers or at the health Centre like clinics among others (36.2%), also 58.5% revealed that
the child was old enough to breastfeed while few of 5.3% showed that they felt that breast milk was no longer
adequate. Also majority of 63.9% showed that the first food that was first introduced to the child was cowmilk
while 5.8% cited on porridge (millet). Respondents were asked whether the child has been unwell in the past
month. The graph belowshows the results;
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80%
74%

70%

60% Page | 100

50%

40%

30%
26%
20%

10%

0%
YES NO

Graph 1: Whether the child has been unwell in the past month

From the graph, majority of respondents showed that their children were unwell in the past monthunlike 26% their
children were well. Thus they had good health. The findings implied the childrenwere affected by malnutrition since
their mothers stopped breastfeeding them in an earlier stage.
Mothers were asked to state the child illness. The results are summarized in the graph below.

40%

35% 33%

30%

25%

20%

15%

10%

5%

0%
failure to thrive diziness weight loss muscle weakness
or loss of muscle

Graph 2: The state the child illness

Majority 35% of mothers revealed that their children experienced weight loss, 33% agreed that their children failed
to thrive, 15% their children experienced dizziness unlike 14% showed that their children experienced muscle
weakness or loss of muscles. These findings shows the signs and symptoms of malnutrition. On other hand mothers
were asked signs and symptoms of a child suffering from kwashiorkor ormarasmus
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Table 6 Signs and symptoms of Kwashiorkor and marasmus

Disease SYMPTOMS Frequency Percentage

KWASHIORKOR Delayed growth in children 115 44
A swollen stomach 91 34.9
Frequent infections 30 11.5 Page | 101
Skin rash 15 5.7
diarrhea 10 3.8
TOTAL 261 100
Dry skin eyes 60 22.9%
MARASMUS Low immunity 100 38.3%
Respiratory infections 81 30.1%
Weight loss 20 7.6%
TOTAL 261 100
On kwashiorkor, majority of 34.9% revealed that the child experience a swollen stomach unlike few of 3.8% showed
that the child experience massive diarrhea. Also on a child suffering marasmus, majority of mothers 38.3% agreed
that the child is usually have low immunity unlike 7.6% cited on weight loss. Also mothers were asked who cares
their children when they are away. The results are tabulatedbelow.
Table 7: The care of a child
The child is left cared by others
YES 261 100%
Total 261 100
Who takes care of this child when you are away?

Older siblings 100 38.3%

maid 148 56.7%

Grandmother 10 13.9%
Neighbors 3 1.1%

TOTAL 261 100

The physical appearance of the child

Clothes unclean 60 22.9%

Nose unwiped 100 38.3%
Face unwashed 81 30.1%
Body dirty 20 7.6%

Total 261 100

All respondents 100% revealed that the child is left cared by others. However 56.75% showed thatthe children is
looked after by the maid, 38.3% cited on older siblings, 13.95 cited on grandmother unlike few of 1.1% cited on
neighbors.On the physical appearance of the child, majority of children 38.3% their children, nose were unwiped,
30.1% faces were unwashed, 22.9% clothes were unclean unlike 7.6% the body were dirty. The findings implied that
mothers were careless about their children as they were in bad conditions.

CONCLUSION

In the present study illiteracy and poverty were the major factors contributing to malnutrition in children while
recurrent diarrhea and non-exclusive breast feeding were directly responsible for it. High prevalence of
undernutrition was observed in our setting and the majority of severely malnourished children were marasmic.
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Children with single parents, who were fed on unbalanceddiet, unvaccinated or who were partially vaccinated and
those whose parents had lower level of education were more likely to be severely malnourished.
RECOMMENDATIONS
Health workers should do village outreaches to sensitize parents on prevention of malnutrition andadvocate for early
seeking of health services in case. The government should provide income generating activities for those in the
informal sector, so that they can make extra income to feed their children and prevent malnutrition. Parents should
be sensitized and briefed in their local language to prevent re admissions; it is possible that the children re admitted
have not followed the feeding program suggested at the unitor either their parents are not in position to sustain the Page | 102
feeding programs. We recommend routine screening for malnutrition to be done in every child who attends the
hospital and nutritional counseling be done to their parents in order to prevent their children from severe
malnutrition. The government should consider increasing the staff at the hospital nutritional unit to ensure that as
these children are admitted they are promptly attended to, and discharged. The government should provide the
required medicines for managing acute server malnutrition and also support the unit with children feeds so that
children don’t lack medicines and end up staying long on hospital admission.
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